Objective: To establish whether savings could be made by changing patients from intramuscular to high doses of oral vitamin B12 in primary care without compromising their wellbeing.

Methods: Cost-minimization analysis from a UK perspective, using secondary data obtained from the literature available and expert opinion.

Results: The cost of the resources used to treat patients with vitamin B12 deficiency with intramuscular vitamin B12 was calculated as between pound55.99 (euro83.1) and pound99.99 (euro148.5) per year. The cost of treating patients with high doses of oral vitamin B12 during the first year was between pound125.55 (euro186.5) and pound248.55 (euro369.1). However, once patients receiving intramuscular treatment had been converted to oral treatment, or in new patients treated orally from the outset, the cost was pound35.55 per year (euro52.8). One variable, home visits, had a high impact on the calculations.

Conclusion: Switching patients with vitamin B12 deficiency from intramuscular to high-dose oral therapy and treating patients newly diagnosed with vitamin B12 deficiency with oral vitamin B12 from the outset could save resources in the medium and long term, and in newly diagnosed patients. Savings would come particularly in the form of nursing time.

dimarts, de setembre 12, 2006

An expert in public health has warned that more potentially deadly illnesses on a front-line warship could follow after two further cases of active tuberculosis (TB) were diagnosed on a Westcountry-based vessel. The Ministry of Defence (MoD) has confirmed that five crew members of HMS Ocean, the Devonport-based amphibious helicopter carrier and assault ship, now have the infectious form of the disease after TB first emerged in May.The unidentified crewmen have been prescribed with up to six months of antibiotics to keep the life-threatening illness under control.The MoD last night said that all five cases of active TB were confined to the marine engineering department, which is responsible for mechanics and electrics. Fifty-five latent forms of the illness emerged on board following a screening process of the entire crew.The latent form produces no symptoms and is not contagious, as the bacteria are not active, although they can become active in later life if another disease puts pressure on the immune system.The MoD said the two new cases of active TB had developed from the 29 latent forms apparent within the marine engineering department. The source of the original infection is still not known.Dr Josep Vidal-Alaball, a GP and specialist registrar for the National Public Health Service for Wales, an expert in the disease, said that if all of the crew members had been screened there was every chance of limiting the full-blown infection. As such, sailors with latent TB have been given a three-month course of antibiotics.Dr Vidal-Alaball, a former doctor at Plymouth's Derriford Hospital, said: "There could be more. There have been a lot of outbreaks in prisons, and it's a very similar situation - people together in a small space for a long time with a lack of ventilation."He said the level of the disease would only be a major concern if around 10 per cent of the 400-strong crew were taken ill with active TB - a figure that would be "very high". He said: "People outside the ship shouldn't be concerned."Rates of TB have been rising in the UK in recent years, with 7,000 cases being reported last year. The disease is most common in the lungs and lymph glands. TB is responsible for three million deaths a year worldwide, mainly in developing countries.A spokesman for the Ministry of Defence said of HMS Ocean: "There are now five [cases of active TB] of which two were suspected at the end of last week. One member of the crew developed TB earlier this year and there have been four further with active TB."HMS Ocean is docked in Devonport ahead of deployment for low-flying helicopter exercises over Wales and the South West on Monday.The ship was moored away from its Westcountry home when the latest cases of TB emerged after it had been withdrawn from last weekend's Navy Days event at Devonport after consideration was given to public health and confidence.The third crew member struck down with tuberculosis has already returned to service.

On 10 February 2004, the specialist respiratory nurse for a hospital in a city in South Wales alerted the local health authorities that Mycobacterium tuberculosis infections in a particular area of the city appeared to be higher than expected in a relatively young age group. All the cases were in patients who reported visiting a particular pub (bar) regularly.As a result of this alert, an outbreak investigation team compiled an initial list of six possible associated cases in five men and one woman who were aged between 25 and 55 years and all lived in the city. Initial interviews established that there were many shared social links between the patients, who were part of a network of regular drinkers at four pubs in a suburb of the city. The interviews were difficult because of the complexity of social relations and reluctance by some of the patients to provide information about their social and sexual life. All reported regularly visiting a certain pub (Pub A) in the area. By October 2004, two further linked cases had been diagnosed.To determine whether there were any other linked tuberculosis cases, all local pubs mentioned by cases were visited, surrounding hospitals were contacted, letters were sent to primary care physicians, and primary care tuberculosis prescribing data collected from primary care, was analysed to detect unusual patterns. No other cases were identified as a result.During 2005, two further cases of M. tuberculosis infection were diagnosed in the same area of the city, also in people who had links with Pub A. Tuberculosis typing (VNTR method) showed that the cases had identical profiles to cases 1, 2, 3, 5 and 6. Both patients were already known to the outbreak investigation team: case 8 had been named but not identified during the initial investigations and case 9 had been screened and initially cleared, but later confirmed through fine needle aspirate of the lung. No new social contacts were identified from these last two cases.Contact tracing established that 2/20 household contacts (10%) and 3/18 social contacts screened (17%) required prophylactic antibiotics.Genetic typing of all cultures was undertaken. PCR-based variable number tandem repeat (VNTR) method for tuberculosis typing was performed. Cases 1, 2, 3, 5 and 6 had identical profiles. An earlier case in a patient who had presented in August 2002 was not microbiologically related to other cases. This case was therefore not considered to be part of the outbreak, and is not included in the Table. No genetic information was available for case 4, as the diagnosis was made while the case was travelling in Australia or for case 7 as this was a clinical diagnosis with a negative culture.In 2006, the local health authorities have continued to liaise with primary care physicians, respiratory nurses and chest physicians, but no further related cases have been identified.

ConclusionThis outbreak of nine cases included seven cases with identical microbiologicalprofiles, one case that was diagnosed on clinical grounds and one case that was diagnosed outside the United Kingdom. All nine patients were local residents of white ethnicity (unusual in patients in the UK) who reported a history of drinking in Pub A. Tuberculosis typing allowed one earlier case to be excluded from the outbreak.In this particular outbreak it has been very difficult to take reliable medical histories due to a combination of poor history telling on the part of the patients and the complex social context in which the outbreak took place. Other authors have previously reported that conventional contact tracing has been insufficient in tuberculosis outbreaks linked to pubs [1]. Without genetic typing it would have been very difficult to establish links between cases in this outbreak. With tuberculosis typing (VNTR method) now routinely available in Wales for all positive cultures, we may see further cases linked to this outbreak in the future.

Treatment of B12 deficiency is important to prevent progressive neurological and/or hematologic disease but requires a secure diagnosis. The aim of this study was to evaluate second line tests of B12 status as prognostic indicators of a hematologic response to vitamin B12 therapy. Forty-nine patients referred with low, serum vitamin B12 concentrations were treated with intramuscular B12 and re-assessed after 3 months. Methylmalonic acid, homocysteine, holotranscobalamin and neutrophil hypersegmentation index were measured before and after treatment. Before treatment 27/49 patients were anemic or macrocytic of whom 15 had a clear hematologic response. All the tests had a similar prognostic accuracy. Symptomatic improvement did not correlate with hematologic response. Supplementary tests of vitamin B12 status were not significantly better than total serum B12 concentration as predictors of a hematologic response to vitamin B12 therapy.

Background: Vitamin B12 deficiency is common and rises with age. Most people with vitamin B12 deficiency are treated in primary care with intramuscular vitamin B12 which is a considerable source of work for health care professionals. Several case control and case series studies have reported equal efficacy of oral administration of vitamin B12 but it is rarely prescribed in this form, other than in Sweden and Canada. Doctors may not be prescribing oral formulations because they are unaware of this option or have concerns regarding effectiveness.Objectives: To assess the effectiveness of oral vitamin B12 versus intramuscular vitamin B12 for vitamin B12 deficiency.Search strategy: Searches were undertaken of The Cochrane Library, MEDLINE, EMBASE and Lilacs in early 2005. The bibliographies of all relevant papers identified using this strategy were searched. In addition we contacted authors of relevant identified studies and Vitamin B12 research and pharmaceutical companies to enquire about other published or unpublished studies and ongoing trials.Selection criteria: Randomised controlled trials (RCTs) examining the use of oral or intramuscular vitamin B12 to treat vitamin B12 deficiency.Data collection and analysis: All abstracts or titles identified by the electronic searches were independently scrutinised by two reviewers. When a difference between reviewers arose, we obtained and reviewed a hard copy of the papers and made decisions by consensus. We obtained a copy of all pre-selected papers and two researchers independently extracted the data from these studies using piloted data extraction forms. The whole group checked whether inclusion and exclusion criteria were met, and disagreement was decided by consensus. The methodological quality of the included studies was independently assessed by two researchers and disagreements were brought back to the whole group and resolved by consensus.Main results: Two RCT's comparing oral with intramuscular administration of vitamin B12 met our inclusion criteria. The trials recruited a total of 108 participants and followed up 93 of these from 90 days to four months. High oral doses of B12 (1000 mcg and 2000 mcg) were as effective as intramuscular administration in achieving haematological and neurological responses.Authors' conclusions: The evidence derived from these limited studies suggests that 2000 mcg doses of oral vitamin B12 daily and 1000 mcg doses initially daily and thereafter weekly and then monthly may be as effective as intramuscular administration in obtaining short term haematological and neurological responses in vitamin B12 deficient patients.

Risk Communication• Is an interactive process of exchange of information• People’s fears should be taken seriously and steps should be taken to address them even if they are not necessary from a technical perspective• Management of Environmental Health issues requires more than technical expertise. Social issues such as house prices, house ownership or stigma of the neighbourhood are also important and should be considered from day one

Risk perception• Clearly, emotions play a large role in public perception of risk• When people become aware of a threat, they are naturally inclined to:– Fear the unknown– Want to maintain control– Protect home and family– Be alienated by dependence on others (government, industry officials)– Protect their belief in a just world• Experts and responsible authorities often think that the perception of the public is mistaken and irrational.• They then try to correct the mistaken perception by the dissemination of information containing the "true" facts about the health risks.• This nearly always fails. Technical measures alone are not enough to ease people’s worries !

• Risks are generally more worrying if perceived:– To be involuntary– As inequitably distributed, some benefit while others suffer– As inescapable by taking personal precautions– To arise from an unfamiliar or novel source– To result from man-made, rather than natural sources– To cause hidden and irreversible damage with onset many years later– To pose particular danger to small children or pregnant women or more generally future generations– To threaten a form of death (or illness/injury) arousing particular dread– To damage identifiable rather than anonymous victims– To be poorly understood by science– As subject to contradictory statements from responsible sources (or even worse, from the same source), or from untrustworthy source.– Invisible or undetectable, catastrophic, memorable, uncertain, uncontrollable or unethical risk.

Risk Comparisons• Often, an involuntary risk is compared with a voluntary one (e.g. the risk from nearby incinerator is compared with smoking or dietary habits). If such a comparison is done in the spirit of minimising the importance of the involuntary risk, it will generate anger.• The value of risk comparisons is also limited by the fact that risks tend to accumulate in people's minds. No matter how small the new risk, people are inclined to see it as simply one more unwelcome vexation to add to their already heavy burden of coping with modern-day problems.

Some problems….• Health Authorities: Very late engagement with unrealistic expectation to respond• Lack of consultation can result in:– inaccurate health messages– raised expectation– unnecessary community concern

Some solutions ….• Openness and transparency– Trust should be based on mutual respect– Communication should be open and honest– An open communication process with the public and the media can be achieved by organising public meetings, issuing press reports, sending letters to residents, fact sheets, setting up internet sites, etc– The language used should be understandable for the general public• Do not let the media take control of the situation. Ensure that key people responsible for communication are always available and ensure a smooth hand-over between various people involved in the case.• Engage early with Health Authorities!

Who is it for?GPs and any doctor with an interest in family planning.When did you do it?In 2002, during my GP registrar year.Why did you do it?In general practice we see many patients wanting advice on family planning and I wanted to have a diploma certifying my proficiency in this specialty. I like the way the diploma is assessed—it requires practical and theoretical training.How much effort did it entail?The diploma has two components; a basic theoretical course and a practical training.There are several approved courses available around the country, which take place over three consecutive days. You organise your own practical training, which needs to be supervised by a faculty approved instructing doctor.Is there an exam? (and fee)No, this is the great thing about the DFFP; no exam is required to obtain the diploma. There is a fee to go to the theoretical course and you may need to pay a small fee to attend practical training.Top tipBook your theoretical course early, as they are quite popular and GP registrars get priority. Organise your clinical placements in advance as it may take several months to attend all the required sessions.Contact for further informationThe Faculty of Family Planning and Reproductive Heath Care, 27 Sussex Place, Regent’s Park, London, NW1 4RG (020 7724 5669; http://www.ffprhc.org.uk/).Was it worth it?ProsNo exams required.Good practical experience through direct patient contact.Once you have the qualifications, you can earn extra income in family planning sessions.Looks good on your CV.Yearly subscriptions to the Faculty of Family Practice not as costly as with other memberships.ConsIt is time consuming as you need to attend several training sessions in recognised training facilities and these may take place in the evenings.It is strange to pay to see patients.The logbook certifying your clinical experience is painful to fill in.You need recertification every five years

I am in favour of Appraisal and Continuous Professional Development for health care professionals but I also strongly believe that any intervention in Health Services needs to be evaluated. The efficacy of Revalidation and Appraisal needs to be evaluated moreover when this is going to be an expensive intervention. I was surprised to find very vague references about evaluation on the Department of Health web side mainly regarding at the number of doctors appraised and the quality of the process.

In a discussion group during one session of the Masters of Public Health at the UWCM in Cardiff I asked how we could possible evaluate Revalidation and Appraisal. We though that it is difficult to evaluate an intervention when the objectives of the intervention are not clear. According to the objectives of the intervention we can design a correct evaluation.

Looking at the numbers of doctors appraised and revalidated is a measure of activity but not a measure of outcome of the intervention. If the objective of appraisal and revalidation is to avoid another Shipman them we should be looking at mortality as outcome and we should be comparing mortality rates amongst doctors. If we want to assess doctor’s performance and improve patient’s care maybe we should be looking at markers of good quality of care. For example we could be looking at the use of Aspirin and B-Blockers after myocardial Infarction or the use of statins. We may find like Dr Manesh Patel, a cardiology fellow at Duke Clinical Research Institute, that educating health care professionals does not improve the care of their patients.

I believe that no evidence for a potential positive intervention should not preclude implementing it. However we should expect a clear evaluation of the intervention in order to justify the use of health care resources .